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GUNDERSEN LUTHERAN MEDICAL CENTER
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on record review and interview, the facility failed to ensure the Pt Rights brochure provided to Pts upon admission includes all Pt rights, in 1 of 1 brochure reviewed.
Findings include:
Per review of facility Pt Rights brochure titled "Patient Rights and Responsibilities", updated 8/14, does not include the following rights:
To participate in the development and implementation of his or her plan of care.
To formulate an advance directive.
To have family or representative and own physician notified upon admission to the hospital.
To personal privacy.
To receive care in a safe setting.
To be free from all forms of abuse or harassment.
To be free from restraints and seclusion.
To have visitors of his or her own choice.
The above was reviewed and confirmed in interview with Senior Consultant H on 5/26/15 at 3:45 PM, who acknowledge some of the rights were missing.
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview, the facility failed to ensure there is documentation if Pts refused meals, in 1 of 10 MRs reviewed.
Findings include:
Per interview on 5/20/15 at 12:35 PM with C A, C A stated Pt #1 cannot self feed. C A alleges a family member visited Pt #1 while in the hospital between 4/23/15 and 4/25/15, and found food trays untouched left in Pt #1's room.
Pt #1's MR review revealed on 4/25/15 at 8:35 AM RN D documented Pt #1 is a "total feed" (unable to feed self). There is no documentation that Pt #1 was fed on 4/25/15 between Midnight and 4:56 PM.
Per interview with RN D on 5/27/15 at 2:00 PM, RN D confirmed the documentation that Pt #1 cannot feed self, adding s/he did not feed Pt #1 on 4/25/15.
Per interview with CNA E on 5/27/15 at 2:00 PM, CNA E recalled Pt #1 refused to eat breakfast and lunch, and confirmed that s/he did not document Pt #1 refused the meals.